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Ahmad SAIH, Holtrop J, van den Eijnden MJM, Jonkman NH, van Pampus MG, van den Heuvel OA, Broekman BFP, Schonewille NN. Family planning decision-making in relation to psychiatric disorders in women: a qualitative focus group study. Reprod Health 2024; 21:96. [PMID: 38956660 PMCID: PMC11221133 DOI: 10.1186/s12978-024-01836-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Recent studies revealed an elevated likelihood of unintended pregnancies among women with psychiatric disorders compared to their counterparts without such vulnerability. Despite the importance of understanding family planning decision-making in this group, qualitative inquiries are lacking. This study explored family planning decisions among women with psychiatric disorders. METHODS Utilizing a qualitative approach, three focus group discussions were conducted with purposive sampling: women with a history of unintended pregnancies (N = 3), women without children (N = 5), and women with a history of intended pregnancies (N = 9), all of whom had self-reported psychiatric disorders. Using thematic framework analysis, we investigated the themes "Shadow of the past," reflecting past experiences, and "Shadow of the future," reflecting future imaginaries, building upon the existing "Narrative Framework." RESULTS The Narrative Framework formed the foundation for understanding family planning among women with psychiatric disorders. The retrospective dimension of focus group discussions provided opportunities for reflective narratives on sensitive topics, revealing emotions of regret, grief and relief. Childhood trauma, adverse events, and inadequate parenting enriched the "Shadow of the past". The "Shadow of the present" was identified as a novel theme, addressing awareness of psychiatric disorders and emotions toward psychiatric stability. Social influences, stigma, and concerns about transmitting psychiatric disorders shaped future imaginaries in the shadow of the future. CONCLUSIONS This study enlightens how family planning decision-making in women with psychiatric disorders might be complex, as marked by the enduring impact of past experiences and societal influences in this sample. These nuanced insights underscore the necessity for tailored support for women with psychiatric disorders.
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Affiliation(s)
- Shahenda A I H Ahmad
- Department of Psychiatry and Medical Psychology, OLVG, Oosterpark 9, Amsterdam, 1091 AC, The Netherlands
| | - Jorina Holtrop
- Department of Psychiatry and Medical Psychology, OLVG, Oosterpark 9, Amsterdam, 1091 AC, The Netherlands
| | | | - Nini H Jonkman
- Department of Research and Epidemiology, OLVG, Oosterpark 9, Amsterdam, 1091 AC, The Netherlands
| | - Maria G van Pampus
- Department of Gynecology and Obstetrics, OLVG, Oosterpark 9, Amsterdam, 1091 AC, The Netherlands
| | - Odile A van den Heuvel
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
- Department of Anatomy and Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
- Compulsivity, Impulsivity and Attention Program, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Birit F P Broekman
- Department of Psychiatry and Medical Psychology, OLVG, Oosterpark 9, Amsterdam, 1091 AC, The Netherlands
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - Noralie N Schonewille
- Department of Psychiatry and Medical Psychology, OLVG, Oosterpark 9, Amsterdam, 1091 AC, The Netherlands.
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands.
- Amsterdam Public Health, Mental Health Program, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands.
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John R, Tudose G, Kuo C, Arth G, Wong S. Ethical challenges in the treatment of psychotic pregnancy denial. Front Psychiatry 2024; 15:1337988. [PMID: 38370555 PMCID: PMC10869507 DOI: 10.3389/fpsyt.2024.1337988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
Background There is a paucity of literature regarding ethical strategies for treating pregnant people with psychosis. While not uncommon, psychotic pregnancy denial is a psychotic illness in which patients have the delusion that they are not pregnant. The authors provide a literature review regarding psychotic pregnancy denial, present an unpublished case and its questions and dilemmas, and offer recommendations for resolving the ethical challenges these cases raise. Case A 26-year-old, single, unemployed woman of no fixed residence was admitted for suicidal ideation. She had a history of psychosis, had multiple ER visits and at least one previous hospitalization, had minimal contact with psychiatric outpatient clinics, and had been poorly compliant with treatment recommendations. She was discovered to be about 31 weeks pregnant in the emergency room. Ultrasound exams revealed no fetal anomalies. This was the patient's second pregnancy; her previous pregnancy resulted in an abortion. Her sole psychotic symptom was the delusional belief that she was not pregnant. On the rare occasions when the patient acknowledged being pregnant, she requested termination of pregnancy. Despite intensive pharmacological treatment of her psychosis, the patient continued believing that she was not pregnant and repeatedly said she would not participate in the labor and delivery process. She disagreed with the induction of labor or a cesarean section if needed. The patient developed gestational hypertension, an obstetric indication for delivery. Induction of labor was offered to avoid potentially disastrous outcomes for the pregnant woman and the fetus. Conclusion Psychotic pregnancy denial is potentially life-threatening. Delivery of the fetus requires carefully weighing risks and benefits and thoroughly considering the ethical framework. Teaching points Treatment of birthing people with psychotic denial of pregnancy is complex; it requires special clinical and ethical skills to determine the patient's level of decision-making impairment and to find a middle ground between the pregnant person's right to autonomy and the physicians' beneficence-based duties. Using a well-coordinated, interdisciplinary approach and a solid ethical framework, the decision to deliver the fetus while engaging the pregnant person, to the extent possible, in the decision-making process is essential.
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Affiliation(s)
- Roshen John
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Gabriel Tudose
- Department of Psychiatry, SUNY Downstate, New York, NY, United States
- Department of Psychiatry, Maimonides Medical Center, New York, NY, United States
| | - Chin Kuo
- Department of Psychiatry, Maimonides Medical Center, New York, NY, United States
| | - Gabriella Arth
- Department of Psychiatry, Maimonides Medical Center, New York, NY, United States
| | - Sammi Wong
- Department of Psychiatry, Brookdale Hospital Medical Center, New York, NY, United States
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Hasser C, Ameresekere M, Girgis C, Knapp J, Shah R. Striking the Balance: Bipolar Disorder in the Perinatal Period. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:3-15. [PMID: 38694148 PMCID: PMC11058914 DOI: 10.1176/appi.focus.20230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
The authors reviewed the literature, published between 2018 and 2023, on treating bipolar disorder in the perinatal period in order to summarize current treatment perspectives. Mood episodes occur during pregnancy and there are high rates of both initial onset and recurrence in the postpartum period. Bipolar disorder itself is associated with higher risks of adverse pregnancy outcomes, including gestational hypertension, hemorrhage, cesarean delivery, and small for gestational age infants. A general principle of perinatal treatment includes maintaining psychiatric stability of the pregnant person while reducing medication exposure risk to the fetus. A variety of factors can compromise psychiatric stability, including rapid discontinuation of stabilizing medications, decreased efficacy due to physiologic changes of pregnancy, and exacerbation of underlying psychiatric illness. Psychosocial interventions include optimizing sleep, increasing support, and reducing stress. The American College of Obstetricians and Gynecologists recommends against discontinuing or withholding medications solely due to pregnancy or lactation status. Individualized treatment involves a discussion of the risks of undertreated bipolar disorder weighed against the risks of individual medication choice based on available evidence regarding congenital malformations, adverse neonatal and obstetrical events, and neurodevelopmental outcomes. Valproate is not a first-line treatment due to higher risks. Data are lacking on safety for many newer medications. The authors review current safety data regarding lithium, lamotrigine, and antipsychotics, which are the most commonly used treatments for managing bipolar disorder in the perinatal period. Due to physiologic changes during pregnancy, frequent therapeutic drug monitoring and dose adjustments are required.
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Affiliation(s)
- Caitlin Hasser
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Maithri Ameresekere
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Christina Girgis
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Jacquelyn Knapp
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Riva Shah
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
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